Corrective Action Plans

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Corrective Action Plan June 30, 2024 67 Finding 2024-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.667 Social Service Block Grant Program 21.027 Coronavirus State and Local Fiscal Recovery Funds Program Federal Agency U.S. Department of Health and Huma...
Corrective Action Plan June 30, 2024 67 Finding 2024-001 Noncompliance with Federal and State Reporting Requirements Assistance Listing Numbers 93.667 Social Service Block Grant Program 21.027 Coronavirus State and Local Fiscal Recovery Funds Program Federal Agency U.S. Department of Health and Human Services Passthrough Agency Illinois Department of Human Services Award Number/Year 2024 Condition UFC did not submit its audited financial statements and SEFA to the Federal Audit Clearinghouse website within nine (9) months of June 30, 2024. UFC also didn’t submit its audited financial statements, SEFA, CFR, CYEFR and other required information to the GATA portal within nine (9) months after June 30, 2024. Views of Responsible Officials and Planned Corrective Actions Management concurs with the auditor’s finding and will 1) hire personnel within the accounting and finance department so that all defined tasks can be performed in a more timely manner and 2) evaluate current processes to determine how to make them more efficient so that the current personnel within the accounting and finance department are able to complete their tasks in a more timely manner. Persons Responsible: Marlin Bryant, CFO Date of Implementation: September 2025
Management agrees with the findings and recommendation. The District has updated its policies and procedures during 2025 to ensure they meet the Uniform Guidance Requirements.
Management agrees with the findings and recommendation. The District has updated its policies and procedures during 2025 to ensure they meet the Uniform Guidance Requirements.
Audit Finding Item 2024-001 Corrective Action Taken: In response to this finding, Tulsa Cares is developing and will formally adopt written procurement policies and procedures in alignment with the requirements outlined in 2 CFR 200.318(a). These policies will establish standards of conduct, ensure ...
Audit Finding Item 2024-001 Corrective Action Taken: In response to this finding, Tulsa Cares is developing and will formally adopt written procurement policies and procedures in alignment with the requirements outlined in 2 CFR 200.318(a). These policies will establish standards of conduct, ensure full and open competition, and provide clear guidance for the procurement of goods and services under federal awards. This corrective action will be completed by the next board meeting, scheduled for December 4, 2025. Responsible Party: Natalie Jarred, Chief Financial and Administrative Officer, is responsible for monitoring compliance with procurement policies and updating them as necessary.
View Audit 368292 Questioned Costs: $1
Finding 2024-002 AL No.: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of Treasury Award Number/Year: 1505-0271 / 2021 Criteria: The Uniform Guidance requires that local entities receiving federal awards establish and maintain intern...
Finding 2024-002 AL No.: 21.027 Program Title: COVID-19 Coronavirus State and Local Fiscal Recovery Funds Federal Agency: U.S. Department of Treasury Award Number/Year: 1505-0271 / 2021 Criteria: The Uniform Guidance requires that local entities receiving federal awards establish and maintain internal control designed to reasonably ensure compliance with laws, regulations, and program compliance requirements. The Uniform Guidance further requires auditors to obtain an understanding of the local entity's internal control over federal programs. To minimize the risk of errors, internal controls should be in place for all program compliance requirements, including the preparation and submission of financial reports, which should be reviewed and approved by a responsible party other than the original preparer before they are submitted to the granting agency. Condition and Context: A sample of one annual P&E report was selected for testing. There was no documentation available to support that the report was reviewed and approved by an individual separate from the preparer prior to submission. This sample was not statistically valid. Cause: The City does not have procedures in place requiring an independent person to review the reports before submission. Effect: Reports could be submitted that contain errors, or reports may not be submitted within the allowed reporting periods. Questioned Costs: None noted. Recommendation: We recommend that an employee other than the preparer review all reports before they are submitted to the Department of Treasury and documentation of the review be retained. Management's Response: The Finance Department will have a staff member initial and review the final report before it is submitted on the Department of Treasury website. This will be corrected right away in September 2025 for future reports being filed. Official Responsible for Ensuring the Corrective Action Plan: Carrie Winklbauer Planned Completion Date for the Corrective Action Plan: September 2025
Management concurs with the findings. The closing process will be improved; physical inventory will be taking and improvements for documentation will be made.
Management concurs with the findings. The closing process will be improved; physical inventory will be taking and improvements for documentation will be made.
Finding Number: 2024-001 Planned Corrective Action: For future quarterly Federal Emergency Agency Reports, the County will implement a formal review and documentation process, including signature, to ensure compliance and prevent over or under-reporting of qualified expenses. Anticipated Completion ...
Finding Number: 2024-001 Planned Corrective Action: For future quarterly Federal Emergency Agency Reports, the County will implement a formal review and documentation process, including signature, to ensure compliance and prevent over or under-reporting of qualified expenses. Anticipated Completion Date: 10/1/2025 Responsible Contact Person: Katy Nail
Finding 2024-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-006 Due to cash flow constraints, the Project was not able to repay the replacement reserve. The Project will repay the replacement reserve when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding 2024-005 Due to the financial situation the Project is in at June 30, 2024, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving depos...
Finding 2024-005 Due to the financial situation the Project is in at June 30, 2024, making this deposit is impossible. HUD has agreed to suspend the monthly required debt service savings deposit effective September 1, 2019. Management is negotiating with HUD to get the past debt service saving deposit requirement suspended permanently. If management is successful in negotiations with HUD, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding 2024-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-004 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding 2024-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
Finding 2024-003 Due to cash flow constraints, the Project was not able to repay the nonprofit sponsor’s foundation. The Project will repay the nonprofit sponsor’s foundation when cash is available. If cash becomes available, the anticipated completion date is June 30, 2025.
View Audit 368220 Questioned Costs: $1
Finding: The County’s first quarter 2024 performance report incorrectly included expenditures that were incurred throughout fiscal year 2023. Cause: The County did not have adequate controls or procedures in place to identify the applicable reporting requirements and ensure the information was filed...
Finding: The County’s first quarter 2024 performance report incorrectly included expenditures that were incurred throughout fiscal year 2023. Cause: The County did not have adequate controls or procedures in place to identify the applicable reporting requirements and ensure the information was filed accurately and timely. Recommendation: Management should implement policies and procedures to ensure required reports are completed accurately and filed by their respective due dates as required by the grant agreement and Uniform Guidance. Corrective Action Plan: Effective immediately, the County will put in additional controls and verify all grants are monitored under additional scrutiny and are reported accurately in quarterly reports. Staff Responsible for Implementation: Matt Davis, County Auditor; Mike Sloan, Senior Associate; Jordan Wilson, Grant Associate Implementation Date: December 31, 2025 Status: In progress
April 30, 2025 To: Clausell & Associates, P.C. From: Camille Vickers, Executive Director of West Central Georgia Community Action Council, Inc. Below is the Council’s corrective action plan as it relates to the findings for the fiscal year ending September 30, 2024, Single Audit Act audit. Comment #...
April 30, 2025 To: Clausell & Associates, P.C. From: Camille Vickers, Executive Director of West Central Georgia Community Action Council, Inc. Below is the Council’s corrective action plan as it relates to the findings for the fiscal year ending September 30, 2024, Single Audit Act audit. Comment #2024-001 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED GENERAL (Repeat) Views of Responsible Officials and Planned Corrective Actions: We concur with this finding – Management is in the process of assessing the organizational structure and capacity to provide adequate financial reporting. With Board review and approval of the Council’s financial funding sources, the Council will provide additional training to support the new fiscal officer. The fiscal officer will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. All enhancements will be implemented by July 31, 2025. Concerning the preparation of external reports required by various funding sources, the Council will ensure adequate training is provided to improve the skills and knowledge of key personnel. Policies and procedures will also be revised to support external reporting. Implementation Date: The plan correction date will be completed no later than July 31, 2025. Responsible Person: Camille Vickers, Executive Director, will be responsible for the corrective action. Comment #2024-002 INTERNAL CONTROLS OVER FINANCIAL STATEMENT PREPARATION AND COMPLIANCE WITH RELATED PROVISIONS OF GRANTS AND CONTRACTS SHOULD BE IMPROVED LIHEAP FALN 93.568 (Questioned Costs – Undetermined) Views of Responsible Officials and Planned Corrective Actions: We concur with this finding – Management is in the process of assessing the organizational structure and capacity to provide adequate financial reporting. With Board review and approval of the Council’s financial funding sources, the Council will provide additional training to support the new fiscal officer. The fiscal officer will have the overall responsibility of properly reconciling and closing out the accounting system and grant activity each month in an efficient and timely manner to eliminate the risk of significant errors occurring. Budget-to-actual schedules will be an integral part of the grant accountant analyst’s basic responsibilities. All enhancements will be implemented by July 31, 2025. Concerning the preparation of external reports required by various funding sources, the Council will ensure adequate training is provided to improve the skills and knowledge of key personnel. Policies and procedures will also be revised to support external reporting. Implementation Date: The plan correction date will be completed no later than July 31, 2025. Responsible Person: Camille Vickers, Executive Director, will be responsible for the corrective action.
View Audit 368208 Questioned Costs: $1
The Foundation must submit all expense documentation to New York State for reimbursement approval. Effective immediately, the Foundation will retain at least two copies of such documentation for support of expenses.
The Foundation must submit all expense documentation to New York State for reimbursement approval. Effective immediately, the Foundation will retain at least two copies of such documentation for support of expenses.
View Audit 368162 Questioned Costs: $1
The Foundation immediately paid the vendor the full amount upon learning of this finding from the auditor and verified that the vendor received the payment. The recording of Grant Revenue/Accounts Receivable and Grant Expenses/Accounts Payable is now done for each grant expense immediately upon appr...
The Foundation immediately paid the vendor the full amount upon learning of this finding from the auditor and verified that the vendor received the payment. The recording of Grant Revenue/Accounts Receivable and Grant Expenses/Accounts Payable is now done for each grant expense immediately upon approval from the Foundation and submission to New York State for reimbursement. This was previously not done. The changes to the recognition of revenue and expenses are already in effect and should eliminate any future finding related to the non-payment of expenses that have been reimbursed through grants.
View Audit 368162 Questioned Costs: $1
Condition: The entity did not retain required support; rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. Planned Corrective Action: Although YMCA performed the proper procedures, the passage of time resulted in a m...
Condition: The entity did not retain required support; rationale for the procurement method, contract type selection, contractor selection or rejection, and the basis for the contract price. Planned Corrective Action: Although YMCA performed the proper procedures, the passage of time resulted in a mis-placing of the supporting documentation. YMCA relied upon legal counsel to retain the documentation. This was a unique and one-time award. In the future, YMCA will take responsibility for the retention of the supporting documentation. Contact person responsible for corrective action: Phillip E. Platz, CFO Anticipated Completion Date: Immediate
View Audit 368158 Questioned Costs: $1
Public and Indian Housing -Assistance Listing No. 14.850 - Inter-Program Recommendation: We recommend the Authority design controls to ensure an adequate review process is in place to ensure inter-program accounts are properly stated at year-end. Explanation of disagreement with audit finding: There...
Public and Indian Housing -Assistance Listing No. 14.850 - Inter-Program Recommendation: We recommend the Authority design controls to ensure an adequate review process is in place to ensure inter-program accounts are properly stated at year-end. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding:The Oklahoma City Housing Authority will develop and document formal procedures for reconciling inter-program accounts. We will establish a secondary review process and create a year-end close checklist that includes inter-program reconciliations. The authority will provide staff training on inter-program account recording and reconciliation requirements. Name(s) of the contact person(s) for corrective action: Jon Reininer Planned completion date for corrective action plan: Review process and checklist creation will be completed 12/31/2025
View Audit 368153 Questioned Costs: $1
Reporting Recommendation: We recommend that management and governance review the financial status reports to supporting documentation and ensure it agrees each month. We recommend management reaches out to their grant contact to ensure cumulative amounts are adjusted through 12/31/2024 to ensure fut...
Reporting Recommendation: We recommend that management and governance review the financial status reports to supporting documentation and ensure it agrees each month. We recommend management reaches out to their grant contact to ensure cumulative amounts are adjusted through 12/31/2024 to ensure future reports are accurate. Explanation of disagreement with audit finding: There is no disagreement with the audit finding. Action taken in response to finding: WCEDC management will continue to work with the Department of Workforce Development and the Wisconsion Economic Development Corporation to clarify expenses through 12/31/2024. Name(s) of the contact person(s) responsible for corrective action: Executive Director Jeff Mikorski Planned completion date for corrective action plan: September – November 2025
Findings & Questioned Costs – Major Federal Award Program Audit – 2024-002 Controls Over Grant Reporting (93.600 Head Start Cluster) Corrective Action Plan: To strengthen internal controls and mitigate this risk, the Council hired a Finance Director / CFO which will enhance oversight. All federal gr...
Findings & Questioned Costs – Major Federal Award Program Audit – 2024-002 Controls Over Grant Reporting (93.600 Head Start Cluster) Corrective Action Plan: To strengthen internal controls and mitigate this risk, the Council hired a Finance Director / CFO which will enhance oversight. All federal grant reports will be prepared by the Finance Director/CFO. All federal grant reports will then subsequently be approved by the Executive Director / CEO prior to final submission. Documented evidence of supervisory review and approval will be maintained with each grant report submission. Implementation Timeline: Completed by September 30, 2025 Responsible Person(s): Finance Director / CFO & Executive Director / CEO
While we acknowledge the auditor’s observation, management does not concur that the absence of formal timesheets equates to unsupported labor charges. Employees completed assigned responsibilities under the Sexual Risk Avoidance Education grant. Salaries were charged consistent with approved budgets...
While we acknowledge the auditor’s observation, management does not concur that the absence of formal timesheets equates to unsupported labor charges. Employees completed assigned responsibilities under the Sexual Risk Avoidance Education grant. Salaries were charged consistent with approved budgets and federal cost principles. During the audited (12-month) period, total payroll expenses allocated to the grant reflected actual performance of program activities as contracted. Accordingly, we believe the costs are fully allowable and the questioned amount of $40,495 is valid program expense. To address auditor concerns, we will utilize the documentation of program detail and timekeeping information within the Educator Tracker to accurately charge time and effort each pay period. The Educator Tracker will include all pertinent details including staff assignments, grant source per assignment, and supervisor approval. Anticipated completion: October 15, 2025. Responsible party: Kimberly Danon, Director of Youth Education.
View Audit 368035 Questioned Costs: $1
The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparatio...
The grant accounting and SEFA preparation process will be refined, improved and documented. Internal resources will be reallocated to ensure sufficient coverage of these processes, and the primary accountability and oversight will shift to System Accounting. Management will ensure that in preparation of the SEFA, (1) a team member will assemble the initial reconciliation, (2) management will review the initial reconciliation and review the consolidation from all BayCare entities to the combined SEFA, (3) A final review will be conducted by the Director of Accounting. Sign-off from each preparer/reviewer shall be required. Meetings will be conducted as needed with departments outside of Hospital Finance to ensure completeness and accuracy of data. Anticipated completion date of Q1 2026.
orrective Action Plan Name of Contact Person Responsible for Corrective Action: John Hunt Centra Health Corporate Director, Information Security and Disaster Recovery 561-613-7342 john.hunt@centrahealth.com Anticipated Completion date: December 31, 2025 Corrective Action: 2024-001 – Special tests an...
orrective Action Plan Name of Contact Person Responsible for Corrective Action: John Hunt Centra Health Corporate Director, Information Security and Disaster Recovery 561-613-7342 john.hunt@centrahealth.com Anticipated Completion date: December 31, 2025 Corrective Action: 2024-001 – Special tests and provisions: As part of our ongoing GLBA compliance efforts, we completed a comprehensive risk assessment on December 24th, 2024. The assessment identified and ranked risks based on likelihood and potential impact to sensitive financial and customer information. In alignment with GLBA’s requirement to safeguard non-public personal information, our program has prioritized remediation and monitoring efforts toward the highest-risk control items identified. Key focus areas include: • Implementing multi-factor authentication for all privileged access, including access to sensitive back-end IT equipment and web application access. • Implementing a vulnerability management program that includes a regular scan of all systems on the network and a programmatic review of the resulting list of vulnerabilities to ensure that systems are reconfigured and patched to address risk to the organization in order of criticality. • Developing a comprehensive Incident Response Plan that is tested and reviewed at least annually or whenever significant changes to procedures are introduced. • Updating Centra’s third-party risk management procedures to include periodic review of supplier performance, appropriateness of information security and data protection controls, and compliance with required controls. • Improving security awareness training with specialized training for specific higher risk roles to the organization. We continue to make progress on 314.4(d)–(g) controls: safeguards have been designed and implemented for high-risk areas, and ongoing testing, training, vendor oversight, and program evaluation are being conducted. Some lower-priority improvements remain in progress, consistent with our risk-based approach and remediation roadmap. These initiatives are tracked, resourced, and scheduled, ensuring that residual gaps are closed in alignment with GLBA requirements.
Finding #2024-001 – Other Noncompliance. Applicable federal program: U. S. Environmental Protection Agency, Passed through Texas Commission on Environmental Quality, Nonpoint Source Implementation Grants, Low Impact Development 2020, Assistance Listing #66.460, Contract period: 11/06/20 – 04/30/26, ...
Finding #2024-001 – Other Noncompliance. Applicable federal program: U. S. Environmental Protection Agency, Passed through Texas Commission on Environmental Quality, Nonpoint Source Implementation Grants, Low Impact Development 2020, Assistance Listing #66.460, Contract period: 11/06/20 – 04/30/26, Contract number: 582-21-10148. Condition and context: Under the terms of its agreement with the Texas Commission in Environmental Quality, HARC receives reimbursement for a percentage of the expenditures incurred in performance of the funded program. Donated services utilized in performance of the program were included in reimbursement submitted to the grantor. Recommendation: Re-emphasize to program and accounting personnel federal grant requirements for the allowability of in-kind donations. Management’s response: Management concurs with the finding. This issue arose because the non-federal flow-through sponsor required certain in-kind cost share amounts to be invoiced as direct expenses, which conflicted with federal cost principles. It is important to note that while the questioned costs increased reported revenue for 2024, the program had unreimbursed expenditures. Corrective actions were implemented in the first half of 2025, including the hiring of new Grants and Contracts Management staff and strengthening of internal controls, to ensure compliance with federal requirements and prevent recurrence in future reporting. Responsible officer: Carmen Osier, Director of Business Operations. Estimated completion date: June 30, 2025.
View Audit 368026 Questioned Costs: $1
Finding 2024-006 See response to finding 2024-002.
Finding 2024-006 See response to finding 2024-002.
View Audit 368025 Questioned Costs: $1
All grant expenditures are reviewed by the Director of Grants and Compliance so that no grant expenditures are paid prior to services being received. The current Director of Grants and Compliance took over this position and procedure in November 2024. The material weakness occurred during a time of ...
All grant expenditures are reviewed by the Director of Grants and Compliance so that no grant expenditures are paid prior to services being received. The current Director of Grants and Compliance took over this position and procedure in November 2024. The material weakness occurred during a time of significant turnover among leadership staff at First Step, prior to the new DIrector of Grants and Compliance taking over this position and procedure. The Director of Grants and Compliance will have the responsibility to ensure the corrective action plan is in place.
View Audit 368008 Questioned Costs: $1
Finding 2024-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evidenc...
Finding 2024-001 Internal Control Deficiency over Allowable Costs Federal Grantor: United States Department of Homeland Security Assistance Listing No.: 97.036 Award Period of Performance: January 1, 2020 – July 1, 2022 Summary of Finding: Management did not consistently retain documentation evidencing the performance of internal controls in place to review and approve FEMA expenditures submitted to the FEMA Portal. Corrective Action Plan: Management implemented corrective action on December 31, 2024 to ensure evidence of controls is retained. Responsible Party: Wah-chung Hsu, Chief Financial Officer Completed Date: December 31, 2024
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